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Thursday, November 03, 2005

Kentucky Ready to Revamp Medicaid


Kentucky prepares to remake Medicaid
New health plans, restrictions would follow federal approval

By Deborah Yetter
The Courier-Journal

FRANKFORT, Ky. — People who use Medicaid could be moved into new health plans with higher costs and more restrictions on services as soon as January, state officials said yesterday.

Several basic health plans would be created to cover adults, children, the elderly and the disabled.

Most Medicaid recipients -- low-income adults and children -- would fall under a plan called "Global Choices," with higher co-payments for medical services and maximum out-of-pocket expenses of $450 a year.

To make these changes and others announced yesterday, Kentucky must have permission from the federal government. State officials said they plan to file the request tomorrow.

If the state gets federal approval, Medicaid would no longer be a program without limits for services or one with little or no cost to the nearly 700,000 Kentuckians it serves.

Other previously announced changes will take effect Jan. 1.

Medicaid will not pay for nonemergency use of emergency rooms and will limit prescriptions to four per month. People who need more prescriptions may get them with advance approval.

Some advocates embraced yesterday's proposal, including members of AARP of Kentucky, who said it could help elderly and disabled people remain at home rather than moving to nursing homes or other institutions.

Under the proposal, Kentucky could reallocate funds to cover more services at home, such as housekeeping and health care for the elderly and disabled.

"I think it's good," said Laurel True, an AARP advocate. "It opens the world up for old people and people with disabilities."

But other advocates said they didn't get enough time to review the 74-page draft of the plan, which was posted on the state's Web site Tuesday night, just hours before a briefing yesterday.

"I'm not sure what the rush is," said Sheila Schuster, a mental-health advocate and head of a coalition of about 70 groups representing people on Medicaid.

And Jan Barthle of Louisville, whose adult daughter Melissa has mental illness and mental retardation, worries that the plan lacks details about how to help people such as her daughter stay out of institutions and live in the community.

Her daughter had to move to a state facility after she lost a community placement because of mental illness, Barthle said.

"They don't address that for my daughter," she said.

The state is facing about a $425 million Medicaid shortfall in the current budget year. Future years will be worse unless the program is radically restructured, Mark D. Birdwhistell, state undersecretary for health, told a group of about 40 advocates and others at the briefing.

"Medicaid has to change," he said.

Health plans

The creation of health plans for Medicaid users concerns Maria Puga, 36, of Lexington, whose five children ages 6 though 15 get health coverage through the service.

She said she would have to pay more for her children's prescription drugs and emergency-room visits -- though children would not be charged co-payments for office visits to the doctor.

Puga said she and her husband both work but have little extra money for medical expenses. Still, she said she'll find a way if it involves her children's health.

"They're my kids," she said. "Even if I have to borrow money from somebody else, I'll do it."

Judy Warner, a social worker at the Family Care Center in Lexington, where Puga's children get care, said she worries about the effect of even small co-payments on low-income families.

"Some of these families I work with, they are at their margin," she said. "It's every month juggling what little bit of money they have."

More comment expected

Birdwhistell and Medicaid Commissioner Shannon Turner said yesterday that the goal is to get Medicaid members more engaged in their health care -- and helping pay for it is one way to do that.

And both said that they will continue to listen to advocates and people who receive Medicaid and will try to address their concerns as officials develop the final health plans.

"The game is not over," Birdwhistell said. He said the plan outlined yesterday will be used to seek federal approval, called a waiver, to reorganize Medicaid.

Federal officials have said they can't comment on Kentucky's plan until they see it. The government provides about 70 percent of Kentucky's Medicaid money.

But Birdwhistell said at a recent meeting that top officials with the federal agency indicated that they like Kentucky's proposals.

Passport unaffected

The plan won't affect about 135,000 members of Passport, a Medicaid managed-care plan that serves people in Jefferson and 15 surrounding counties. Still, Medicaid will be incorporating some of Passport's methods, including tighter controls on prescription drugs and requiring approval in advance for many costly, brand-name drugs.

Steve Conlon, 51, of Louisville, a Passport member who is disabled from a degenerative spinal disease, said he's satisfied with Passport, although he recently was delayed several months from getting a brand-name pain drug until the plan agreed to approve it.

The drug, a time-release form of morphine, replaced several drugs he was taking each day and is more effective, he said.

Conlon said he would have preferred not to go through the lengthy appeal process but was happy with the outcome. "I was in the military -- I know about the chain of command and that's what I had to do," he said.

Necessary service

Bobby Marcum, 45, of Manchester, said he thinks people probably tend to get prescriptions they don't need or use. Higher co-payments and limits might help cut down on abuse, he said.

"I feel like there's a lot of waste out there," said Marcum, who qualifies for Medicaid because he is blind.

Birdwhistell said Medicaid's proposed health plans will limit some services such as X-rays or physical therapy. But people who need more than the plan allows can get them with permission from Medicaid, he said.

"If it's a medically necessary service, they're going to get it," he said.